Curing the Emergency Room

When Dr. Gail Anderson split open his finger in a Saturday backyard accident recently he knew just where to go. The Los Angeles County--University of Southern California Medical Center is only minutes from his home and has one of the best-equipped emergency rooms in the area. The experience was not totally satisfactory, however. Though the injury obviously made writing difficult, a clerk insisted that he fill out a form. Then he had to wait 90 minutes before the finger was stitched.

At least the emergency-room staff could not be accused of favoritism. Upon entering, Anderson had identified himself as the hospital's director of emergency-room medicine. As an E.R. patient, Anderson says, "There were a lot of things I didn't like."

Uneven Quality. He is not alone. There are a great many things that both doctors and laymen dislike about E.R. practice in the U.S. Patients are understandably upset by the often uncaring attitudes of hospital personnel and the uneven quality of treatment. Doctors increasingly share that concern and add that emergency rooms are themselves facing an emergency situation. The principal reasons:

> Demands on E.R.s have increased dramatically. Between 1965 and 1970, hospital admissions in the U.S. rose 11%; E.R. visits increased 49%--though not as a result of rising accident or injury rates. With the continued decline in the number of general practitioners, thousands of patients have begun turning to E.R.s for routine care. According to one nationwide study, more than half of all E.R. patients do not have acute illnesses or injuries, but have nowhere else to go. "The E.R. is the G.P. up here," says Anthony Triulzi, administrator of the 225-bed Kingston (N.Y.) Hospital. "We see everything from cat scratches to gunshots." > Equipment in E.R.s is often poor. A study by the American Hospital Association reveals that of the country's 5,338 community hospitals 5,129 have E.R.s, but almost half lack intensive-care units, 40% lack blood banks, and 58% are unequipped to deal with cardiac emergencies.

> Staffs are often inadequate. Although experienced physicians are "on call," most hospitals use interns to man their emergency rooms day to day. Others hire unlicensed foreign physicians, a practice that can raise dangerous communication problems in the hectic E.R. atmosphere.

While they are concerned about the trend toward using E.R.s as general clinics, hospital authorities recognize that it has gone too far to be reversed. "The use of the emergency department," says Dr. Leon Taubenhaus, director of community health services for New York City's Beekman-Downtown Hospital, "is reflective of the inadequacies of medical care within the community the hospital serves." Gail Anderson, whose facility handles 30,000 patients a month, agrees. "Demands on the emergency room are not going to decrease," he says.

In many areas, steps are being taken to meet those demands. Several hospitals have hired physicians whose full-time job is to oversee emergency-room procedures. Kingston Hospital pays three doctors $30,000 a year each to provide 24-hour E.R. coverage; long lines of patients still form, although the minimum charge to see a doctor is $16. Other hospitals are seeking to improve care by training doctors specifically to treat acute situations. The 2,000-member American Association of Emergency Room Physicians has been pressing to make emergency medicine a recognized subspecialty. U.S.C. has taken a step in this direction by becoming one of the first schools in the country to set up a department of emergency medicine. It has also used a grant from the Department of Health, Education and Welfare to establish a residency in emergency medicine at Los Angeles County Hospital.

Selective Prejudice. New York City's Bellevue Hospital Center has separated its pediatric and psychiatric emergency facilities from its trauma section, installed a 16-bed intensive-care section, an X-ray unit and a computerized laboratory within yards of the emergency entrance. Beekman-Downtown, in the shadow of New York's City Hall, has similar facilities in its newly constructed emergency department, plus an unusual addition: a room with hoses and fans to wash down and aerate those who have been tear-gassed in demonstrations.

The most important changes have been in organization and attitudes. "Patients have to get to the right place," says Dr. Max Weil of Hollywood Presbyterian Hospital. "Personnel must be selectively prejudiced in favor of the individual who can't wait." To promote this sense of discrimination, Weil urges a screening system to separate the critically ill or injured from those in less serious condition. He would direct the remainder to other departments or clinics within the hospital.

Chicago's giant Cook County Hospital, which handles up to 1,000 new patients a day, has already instituted such a system. Instead of a traditional all-purpose emergency room, it has an admitting department run by a doctor who serves as a triage, or sorting officer. He sees each patient within two minutes of admittance, makes a quick decision as to where the patient should go for treatment. The system means that people will not be served in the order of their arrival, but it should go a long way toward providing prompt and proper attention for serious cases--which is what an emergency room is supposed to offer.

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